255 Form 9.6.12



Professional Services Qualifications – 255 FormPROFESSIONAL SERVICES QUALIFICATIONSCDB 255 FORM1. Prequalification No..:2.Firm Name, address, phone & fax numbers: For Joint Venture (“JV”), include information for all members, design discipline of each member, and percentage (of total design team) of services of each member.3.Contact Person:Email Address:4.CDB Bulletin Number: Project Number:Project Description:5.Approximate distance to project location: Miles(Enter n/a if location has not been determined.)6.Percentage of work to be completed by Prime/JV:Certified by CMS?:?MBE?FBE?VOSB?SDVOSB7.Percentage of work to be performed by Consultants that are CMS Certified MBE/FBE firms:Percentage of work to be performed by Consultants that are CMS Certified VOSB/SDVOSB (VBE) firms:*% shall reflect the total of all consultants that are MBE/FBE and VOSB/SDVOSB (VBE) in item 12 8.Certifications & Disclosures. Submit Forms A or B.?Forms A?Forms B (only if vendor is registered in the Illinois Procurement Gateway (“IPG”))Approved IPG Registration No.:9.CDB Standard Business Terms and Conditions Enclosed:?10.Team personnel, by discipline, to be designated for this project including all consultants. Indicate personnel licensed in Illinois. Submit a résumé for each individual listed below in Item 15. DO NOT include clerical and support staff.# Assigned to this project# Licensed in Illinois# Assigned to this project# Licensed in IllinoisArchitectsMechanical EngineersAsbestos Project DesignersStructural EngineersCivil EngineersSurveyorsElectrical EngineersConstruction ObserversOther:TOTALS11.Form must be signed by the Firm’s President, Vice President, Partner or Sole Owner, Joint Venture Designee or any other person authorized to execute business for the firm/JV.Signature:Date:Typed:12.CONSULTANTS: Please list the consultants that will be performing any portion of basic design services for this project. Any firm providing architectural, engineering, asbestos abatement design services or land surveying must be prequalified with CDB.? Consultants?that are not providing the aforementioned regulated services do not have to be prequalified with CDB, but should be registered with CDB as a sub-consultant. These may include cost consultants, food service consultants, etc. The firms listed below are considered first tier consultants and shall hold a contract directly with the firm submitting this 255 Form.Failure of the consultants, providing regulated design services, to be prequalified, will result in rejection of the Prime A/E’s submittal(s).Firm Name & AddressPercentage*Worked with Prime(Yes or No)PrequalificationorRegistration No.Detailed Scope of ServicesCertified by CMS? FORMCHECKBOX MBE FORMCHECKBOX FBE FORMCHECKBOX PBE FORMCHECKBOX VOSB FORMCHECKBOX SDVOSB FORMCHECKBOX MBE FORMCHECKBOX FBE FORMCHECKBOX PBE FORMCHECKBOX VOSB FORMCHECKBOX SDVOSB FORMCHECKBOX MBE FORMCHECKBOX FBE FORMCHECKBOX PBE FORMCHECKBOX VOSB FORMCHECKBOX SDVOSB FORMCHECKBOX MBE FORMCHECKBOX FBE FORMCHECKBOX PBE FORMCHECKBOX VOSB FORMCHECKBOX SDVOSB FORMCHECKBOX MBE FORMCHECKBOX FBE FORMCHECKBOX PBE FORMCHECKBOX VOSB FORMCHECKBOX SDVOSB13.RELEVANT PROJECT EXPERIENCE: (On completed projects within the past 10 years, limit to 8 projects for the submitting firm and 4 for each consultant)Firm Name:Project Description & LocationLevel of Responsibility &Detailed Description of ServicesOwners Name & AddressPrime Contact – Phone & Fax No.(Consultants, identify the Prime A/E)Completion Date MM/YY(Actual or Estimated)Total Project Cost14.TEAM PERSONNEL: Any contract awarded in response to this submittal is conditioned on the qualifications of the firm and the project team individuals as stated below. Therefore, the team listed below shall be assigned to this project if a contract is awarded to the submitting firmNameProject AssignmentAssociated FirmIndividual Professional License(s) or Certification(s)Licensed or Certified in Illinois?15.TEAM PERSONNEL RESUMES:(a) Name and Title(b) Project Assignment(c) Complete Office Address for this Individual(d) Years of Experience with this Firm (with other firms)(e) Education: Institution/Field of Study/Degree/Year Obtained(f) Active Licenses/Certifications/Type/Year(g) Specific Relevant Project Experience Including Individual’s Level of ResponsibilityCDB STANDARD BUSINESS TERMS AND CONDITIONSAVAILABILITY OF APPROPRIATION (30 ILCS 500/20-60): This contract is contingent upon and subject to the availability of funds. The State, at its sole option, may terminate or suspend this contract, in whole or in part, without penalty or further payment being required, if (1) the Illinois General Assembly or the federal funding source fails to make an appropriation sufficient to pay such obligation, or if funds needed are insufficient for any reason, (2) the Governor decreases the Department’s funding by reserving some or all of the Department’s appropriation(s) pursuant to power delegated to the Governor by the Illinois General Assembly; or (3) the Department determines, in its sole discretion or as directed by the Office of the Governor, that a reduction is necessary or advisable based upon actual or projected budgetary considerations. Contractor will be notified in writing of the failure of appropriation or of a reduction or decrease.AUDIT/RETENTION OF RECORDS (30 ILCS 500/20-65): Vendor and its subcontractors shall maintain books and records relating to the performance of the contract or subcontract and necessary to support amounts charged to the State under the contract or subcontract. Books and records, including information stored in databases or other computer systems, shall be maintained by the Vendor for a period of three years from the later of the date of final payment under the contract or completion of the contract, and by the subcontractor for a period of three years from the later of final payment under the term or completion of the subcontract. If federal funds are used to pay contract costs, the Vendor and its subcontractors must retain its records for five years. Books and records required to be maintained under this section shall be available for review or audit by representatives of: the procuring Agency, the Auditor General, the Executive Inspector General, the Chief Procurement Officer, State of Illinois internal auditors or other governmental entities with monitoring authority, upon reasonable notice and during normal business hours. Vendor and its subcontractors shall cooperate fully with any such audit and with any investigation conducted by any of these entities. Failure to maintain books and records required by this section shall establish a presumption in favor of the State for the recovery of any funds paid by the State under the contract for which adequate books and records are not available to support the purported disbursement. The Vendor or subcontractors shall not impose a charge for audit or examination of the Vendor’s books and records. TIME IS OF THE ESSENCE: Time is of the essence with respect to Vendor’s performance of this contract. Vendor shall continue to perform its obligations while any dispute concerning the contract is being resolved unless otherwise directed by the State.NO WAIVER OF RIGHTS: Except as specifically waived in writing, failure by a Party to exercise or enforce a right does not waive that Party’s right to exercise or enforce that or other rights in the future.FORCE MAJEURE: Failure by either Party to perform its duties and obligations will be excused by unforeseeable circumstances beyond its reasonable control and not due to its negligence including acts of nature, acts of terrorism, riots, labor disputes, fire, flood, explosion, and governmental prohibition. The non-declaring Party may cancel the contract without penalty if performance does not resume within 30 days of the declaration.CONFIDENTIAL INFORMATION: Each Party, including its agents and subcontractors, to this contract may have or gain access to confidential data or information owned or maintained by the other Party in the course of carrying out its responsibilities under this contract. Vendor shall presume all information received from the State or to which it gains access pursuant to this contract is confidential. Vendor information, unless clearly marked as confidential and exempt from disclosure under the Illinois Freedom of Information Act, shall be considered public. No confidential data collected, maintained, or used in the course of performance of the contract shall be disseminated except as authorized by law and with the written consent of the disclosing Party, either during the period of the contract or thereafter. The receiving Party must return any and all data collected, maintained, created or used in the course of the performance of the contract, in whatever form it is maintained, promptly at the end of the contract, or earlier at the request of the disclosing Party, or notify the disclosing Party in writing of its destruction. The foregoing obligations shall not apply to confidential data or information lawfully in the receiving Party’s possession prior to its acquisition from the disclosing Party; received in good faith from a third-party not subject to any confidentiality obligation to the disclosing Party; now is or later becomes publicly known through no breach of confidentiality obligation by the receiving Party; or is independently developed by the receiving Party without the use or benefit of the disclosing Party’s confidential information.USE AND OWNERSHIP: All work performed or supplies created by Vendor under this contract, whether written documents or data, goods or deliverables of any kind, shall be deemed work-for-hire under copyright law and all intellectual property and other laws, and the State of Illinois is granted sole and exclusive ownership to all such work, unless otherwise agreed in writing. Vendor hereby assigns to the State all right, title, and interest in and to such work including any related intellectual property rights, and/or waives any and all claims that Vendor may have to such work including any so-called "moral rights" in connection with the work. Vendor acknowledges the State may use the work product for any purpose. Confidential data or information contained in such work shall be subject to confidentiality provisions of this contract.INDEPENDENT CONTRACTOR: Vendor shall act as an independent contractor and not an agent or employee of, or joint venturer with the State. All payments by the State shall be made on that basis.SOLICITATION AND EMPLOYMENT: Vendor shall not employ any person employed by the State during the term of this contract to perform any work under this contract. Vendor shall give notice immediately to the Agency’s director if Vendor solicits or intends to solicit State employees to perform any work under this PLIANCE WITH THE LAW: The Vendor, its employees, agents, and subcontractors shall comply with all applicable federal, state, and local laws, rules, ordinances, regulations, orders, federal circulars and all license and permit requirements in the performance of this contract. Vendor shall be in compliance with applicable tax requirements and shall be current in payment of such taxes. Vendor shall obtain at its own expense, all licenses and permissions necessary for the performance of this contract.BACKGROUND CHECK: Whenever the State deems it reasonably necessary for security reasons, the State may conduct, at its expense, criminal and driver history background checks of Vendor’s and subcontractors officers, employees or agents. Vendor or subcontractor shall reassign immediately any such individual who, in the opinion of the State, does not pass the background checks.APPLICABLE LAW: This contract shall be construed in accordance with and is subject to the laws and rules of the State of Illinois. The Department of Human Rights’ Equal Opportunity requirements (44 Ill. Adm. Code 750) are incorporated by reference. Any claim against the State arising out of this contract must be filed exclusively with the Illinois Court of Claims (705 ILCS 505/1). The State shall not enter into binding arbitration to resolve any contract dispute. The State of Illinois does not waive sovereign immunity by entering into this contract. The official text of cited statutes is incorporated by reference (An unofficial version can be viewed at ). In compliance with the Illinois and federal Constitutions, the Illinois Human Rights Act, the U. S. Civil Rights Act, and Section 504 of the federal Rehabilitation Act and other applicable laws and rules the State does not unlawfully discriminate in employment, contracts, or any other activity.ANTI-TRUST ASSIGNMENT: If Vendor does not pursue any claim or cause of action it has arising under federal or state antitrust laws relating to the subject matter of the contract, then upon request of the Illinois Attorney General, Vendor shall assign to the State rights, title and interest in and to the claim or cause of action.CONTRACTUAL AUTHORITY: The Agency that signs for the State of Illinois shall be the only State entity responsible for performance and payment under the contract. When the Chief Procurement Officer or authorized designee signs in addition to an Agency, they do so as approving officer and shall have no liability to Vendor. When the Chief Procurement officer or authorized designee signs a master contract on behalf of State agencies, only the Agency that places an order with the Vendor shall have any liability to Vendor for that order. NOTICES: Notices and other communications provided for herein shall be given in writing by registered or certified mail, return receipt requested, by receipted hand delivery, by courier (UPS, Federal Express or other similar and reliable carrier), by e-mail, or by fax showing the date and time of successful receipt. Notices shall be sent to the individuals who signed the contract using the contact information following the signatures. Each such notice shall be deemed to have been provided at the time it is actually received. By giving notice, either Party may change the contact information.MODIFICATIONS AND SURVIVAL: Amendments, modifications and waivers must be in writing and signed by authorized representatives of the Parties. Any provision of this contract officially declared void, unenforceable, or against public policy, shall be ignored and the remaining provisions shall be interpreted, as far as possible, to give effect to the Parties’ intent. All provisions that by their nature would be expected to survive, shall survive termination. In the event of a conflict between the State’s and the Vendor’s terms, conditions and attachments, the State’s terms, conditions and attachments shall prevail.PERFORMANCE RECORD / SUSPENSION: Upon request of the State, Vendor shall meet to discuss performance or provide contract performance updates to help ensure proper performance of the contract. The State may consider Vendor’s performance under this contract and compliance with law and rule to determine whether to continue the contract, suspend Vendor from doing future business with the State for a specified period of time, or to determine whether Vendor can be considered responsible on specific future contract opportunities.FREEDOM OF INFORMATION ACT: This contract and all related public records maintained by, provided to or required to be provided to the State are subject to the Illinois Freedom of Information Act notwithstanding any provision to the contrary that may be found in this contract. Signature: Date: Printed Name: Title: Phone Number: Email Address: Effective July 1, 2014 – BIDDERS NOW HAVE TWO OPTIONS FOR PROVIDING THE REQUIRED CERTIFICATIONS AND DISCLOSURES:1. FORMS A –THE STANDARD PAPER METHOD OF REQUIRED DOCUMENTS AND INFORMATION.2. FORMS B AND AN ILLINOIS PROCUREMENT GATEWAY (IPG) REGISTRATION NUMBER WHICH ALLOWS FOR REDUCED DOCUMENTATION WHEN USING AN APPROVED IPG REGISTRATION NUMBER.The Illinois Procurement Gateway is located at . The IPG is a web based system that serves as the primary location for entering, organizing, and reviewing vendor information. The IPG allows vendors to provide disclosures, registrations, and other documentation needed to do business with a State agency or university in advance of any particular procurement, thereby reducing the number of documents needed to be submitted with a bid.The State reviews information submitted through the IPG to register vendors in advance of submitting bids and offers for contracts. Upon satisfactory registration, vendors receive a registration number that may be used when submitting the required forms. Reviews may exceed two weeks when information submitted is incomplete or inaccurate.FORMS A*This Forms A section may be used if you are not using IPG (Illinois Procurement Gateway) Registration #. Forms AA vendor responding to a solicitation by the State of Illinois must return the information requested within this section with their bid or offer if they are not registered in the Illinois Procurement Gateway (IPG). Failure to do so may render their bid or offer non-responsive and result in disqualification.Please read this entire FORMS A section and provide the requested information as applicable and per the instructions. All forms and signature areas contained in this FORMS A section must be completed in full and submitted along with the bid in an Invitation for Bid; and completed in full and submitted along with the technical response and price proposal, which combined will constitute the Offer, in a Request for Proposal.Vendor Name: Phone: Street Address: Email: City, State Zip: Vendor Contact: OUTLINEFORMS A SectionComplete this section if you are not using IPG (Illinois Procurement Gateway) Registration #Document TitleSectionAuthorized to Do Business in Illinois1Standard Certifications2State Board of Elections3Disclosure of Business Operations in Iran..4Financial Disclosures and Conflicts of Interest…5Taxpayer Identification Number61.EVIDENCE OF BEING AUTHORIZED TO DO BUSINESS IS THE SECRETARYOF STATE’S CERTIFICATE OF GOOD STANDINGVendor acknowledges and agrees that compliance with this subsection in its entirety for the term of the contract and any renewals is a material requirement and condition of this contract. By executing this contract Vendor certifies compliance with this subsection in its entirety, and is under a continuing obligation to remain in compliance and report any non-compliance.2. This subsection, in its entirety, applies to subcontractors used on this contract. Vendor shall include these Standard Certifications in any subcontract used in the performance of the contract using the Standard Certification form provided by the State.If this contract extends over multiple fiscal years, including the initial term and all renewals, Vendor and its subcontractors shall confirm compliance with this section in the manner and format determined by the State by the date specified by the State and in no event later than July 1 of each year that this contract remains in effect.If the Parties determine that any certification in this section is not applicable to this contract it may be stricken without affecting the remaining subsections.2.1As part of each certification, Vendor acknowledges and agrees that should Vendor or its subcontractors provide false information, or fail to be or remain in compliance with the Standard Certification requirements, one or more of the following sanctions will apply:the contract may be void by operation of law,the State may void the contract, andthe Vendor and it subcontractors may be subject to one or more of the following: suspension, debarment, denial of payment, civil fine, or criminal penalty.Identifying a sanction or failing to identify a sanction in relation to any of the specific certifications does not waive imposition of other sanctions or preclude application of sanctions not specifically identified.2.2Vendor certifies it and its employees will comply with applicable provisions of the United States Civil Rights Act, Section 504 of the Federal Rehabilitation Act, the Americans with Disabilities Act, and applicable rules in performance of this contract.2.3Vendor, if an individual, sole proprietor, partner or an individual as member of a LLC, certifies he/she is not in default on an educational loan. 5 ILCS 385/3.2.4Vendor, if an individual, sole proprietor, partner or an individual as member of a LLC, certifies it he/she has not received (i) an early retirement incentive prior to 1993 under Section 14-108.3 or 16-133.3 of the Illinois Pension Code or (ii) an early retirement incentive on or after 2002 under Section 14-108.3 or 16-133.3 of the Illinois Pension Code. 30 ILCS 105/15a; 40 ILCS 5/14-108.3; 40 ILCS 5/16-133.2.5Vendor certifies that it is a legal entity authorized to do business in Illinois prior to submission of a bid, offer, or proposal. 30 ILCS 500/1-15.80, 20-43.2.6To the extent there was a current Vendor providing the services covered by this contract and the employees of that Vendor who provided those services are covered by a collective bargaining agreement, Vendor certifies (i) that it will offer to assume the collective bargaining obligations of the prior employer, including any existing collective bargaining agreement with the bargaining representative of any existing collective bargaining unit or units performing substantially similar work to the services covered by the contract subject to its bid or offer; and (ii) that it shall offer employment to all employees currently employed in any existing bargaining unit who perform substantially similar work to the work that will be performed pursuant to this contract. This does not apply to heating, air conditioning, plumbing and electrical service contracts. 30 ILCS 500/25-80.2.7Vendor certifies it has neither been convicted of bribing or attempting to bribe an officer or employee of the State of Illinois or any other State, nor made an admission of guilt of such conduct that is a matter of record. 30 ILCS 500/50-5.2.8If Vendor has been convicted of a felony, Vendor certifies at least five years have passed after the date of completion of the sentence for such felony, unless no person held responsible by a prosecutor’s office for the facts upon which the conviction was based continues to have any involvement with the business. 30 ILCS 500/50-10.2.9If Vendor or any officer, director, partner, or other managerial agent of Vendor has been convicted of a felony under the Sarbanes-Oxley Act of 2002, or a Class 3 or Class 2 felony under the Illinois Securities Law of 1953, Vendor certifies at least five years have passed since the date of the conviction. Vendor further certifies that it is not barred from being awarded a contract and acknowledges that the State shall declare the contract void if this certification is false. 30 ILCS 500/50-10.5.2.10Vendor certifies it is not barred from having a contract with the State based upon violating the prohibitions related to either submitting/writing specifications or providing assistance to an employee of the State of Illinois by reviewing, drafting, directing, or preparing any invitation for bids, a request for proposal, or request of information, or similar assistance (except as part of a public request for such information).? 30 ILCS 500/50-10.5(e), amended by Pub. Act No. 97-0895 (August 3, 2012).2.11Vendor certifies that it and its affiliates are not delinquent in the payment of any debt to the State (or if delinquent has entered into a deferred payment plan to pay the debt), and Vendor and its affiliates acknowledge the State may declare the contract void if this certification is false or if Vendor or an affiliate later becomes delinquent and has not entered into a deferred payment plan to pay off the debt. 30 ILCS 500/50-11, 50-60.2.12Vendor certifies that it and all affiliates shall collect and remit Illinois Use Tax on all sales of tangible personal property into the State of Illinois in accordance with provisions of the Illinois Use Tax Act and acknowledges that failure to comply may result in the contract being declared void. 30 ILCS 500/50-12.2.13Vendor certifies that it has not been found by a court or the Pollution Control Board to have committed a willful or knowing violation of the Environmental Protection Act within the last five years, and is therefore not barred from being awarded a contract. 30 ILCS 500/50-14.2.14Vendor certifies it has neither paid any money or valuable thing to induce any person to refrain from bidding on a State contract, nor accepted any money or other valuable thing, or acted upon the promise of same, for not bidding on a State contract. 30 ILCS 500/50-25. 2.15Vendor certifies it is not in violation of the “Revolving Door” provisions of the Illinois Procurement Code. 30 ILCS 500/50-30.2.16Vendor certifies that it has not retained a person or entity to attempt to influence the outcome of a procurement decision for compensation contingent in whole or in part upon the decision or procurement. 30 ILCS 500/50-38.2.17Vendor certifies that if it has hired a person required to register under the Lobbyist Registration Act to assist in obtaining any State contract, that none of the lobbyist’s costs, fees, compensation, reimbursements, or other remuneration were billed to the State. 30 ILCS 500\50-38. 2.18Vendor certifies it will report to the Illinois Attorney General and the Chief Procurement Officer any suspected collusion or other anti-competitive practice among any bidders, offerors, contractors, proposers, or employees of the State. 30 ILCS 500/50-40, 50-45, 50-50.2.19Vendor certifies steel products used or supplied in the performance of a contract for public works shall be manufactured or produced in the United States, unless the executive head of the procuring Agency/University grants an exception. 30 ILCS 565.2.20Drug Free Workplace4.20.1.If Vendor employs 25 or more employees and this contract is worth more than $5,000, Vendor certifies it will provide a drug free workplace pursuant to the Drug Free Workplace Act.4.20.2.If Vendor is an individual and this contract is worth more than $5000, Vendor certifies it shall not engage in the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance during the performance of the contract. 30 ILCS 580.2.21Vendor certifies that neither Vendor nor any substantially owned affiliate is participating or shall participate in an international boycott in violation of the U.S. Export Administration Act of 1979 or the applicable regulations of the United States. Department of Commerce. 30 ILCS 582.2.22Vendor certifies it has not been convicted of the offense of bid rigging or bid rotating or any similar offense of any state or of the United States. 720 ILCS 5/33 E-3, E-4.2.23Vendor certifies it complies with the Illinois Department of Human Rights Act and rules applicable to public contracts, which include providing equal employment opportunity, refraining from unlawful discrimination, and having written sexual harassment policies. 775 ILCS 5/2-105.2.24Vendor certifies it does not pay dues to or reimburse or subsidize payments by its employees for any dues or fees to any “discriminatory club.” 775 ILCS 25/2.2.25Vendor certifies that no foreign-made equipment, materials, or supplies furnished to the State under the contract have been or will be produced in whole or in part by forced labor or indentured labor under penal sanction. 30 ILCS 583. 2.26Vendor certifies that no foreign-made equipment, materials, or supplies furnished to the State under the contract have been produced in whole or in part by the labor of any child under the age of 12. 30 ILCS 584.2.27Vendor certifies that any violation of the Lead Poisoning Prevention Act, as it applies to owners of residential buildings, has been mitigated. 410 ILCS 45.2.28Vendor warrants and certifies that it and, to the best of its knowledge, its subcontractors have and will comply with Executive Order No. 1 (2007). The Order generally prohibits Vendors and subcontractors from hiring the then-serving Governor’s family members to lobby procurement activities of the State, or any other unit of government in Illinois including local governments if that procurement may result in a contract valued at over $25,000. This prohibition also applies to hiring for that same purpose any former State employee who had procurement authority at any time during the one-year period preceding the procurement lobbying activity.2.29Vendor certifies that information technology, including electronic information, software, systems and equipment, developed or provided under this contract comply with the applicable requirements of the Illinois Information Technology Accessibility Act Standards as published at (dhs.state.il.us/iitaa) 30 ILCS 587.2.30Vendor certifies that it has read, understands, and is in compliance with the registration requirements of the Elections Code (10 ILCS 5/9-35) and the restrictions on making political contributions and related requirements of the Illinois Procurement Code. 30 ILCS 500/20-160 and 50-37. Vendor will not make a political contribution that will violate these requirements. In accordance with section 20-160 of the Illinois Procurement Code, Vendor certifies as applicable: FORMCHECKBOX Vendor is not required to register as a business entity with the State Board of Elections.or FORMCHECKBOX Vendor has registered with the State Board of Elections. As a registered business entity, Vendor acknowledges a continuing duty to update the registration as required by the Act.2.31Vendor certifies that if it is awarded a contract through the use of the preference required by the Procurement of Domestic Products Act, then it shall provide products pursuant to the contract or a subcontract that are manufactured in the United States. 30 ILCS 517.2.32A person (other than an individual acting as a sole proprietor) must be a duly constituted legal entity and authorized to do business in Illinois prior to submitting a bid or offer.? 30 ILCS 500/20-43.? If you do not meet these criteria, then your bid or offer will be disqualified.Vendor must make one of the following four certifications by checking the appropriate box. If C or D is checked, then Vendor must attach to this form the requested documentation.A. FORMCHECKBOX Vendor certifies it is an individual acting as a sole proprietor and is therefore not subject to the requirements of section 20-43 of the Procurement Code.B. FORMCHECKBOX Vendor certifies that it is a legal entity, and was authorized to do business in Illinois as of the date for submitting this bid or offer. The State may require Vendor to provide evidence of compliance before award.C. FORMCHECKBOX Vendor certifies it is a legal entity, and is a foreign corporation performing activities that do not constitute transacting business in Illinois as defined by Illinois Business Corporations Act (805 ILCS 5/13.75).? A vendor claiming exemption under the Act must include a detailed explanation of the legal basis for the claim with its bid or offer and must provide additional detail upon request. If Vendor fails to provide the mandatory documentation with the bid or offer, or does not provide additional detail upon request within the timeframe specified in said request, then the State may deem the Vendor as being non-responsive or not responsible and may disqualify the Vendor.D. FORMCHECKBOX Vendor certifies it is a legal entity, and is an entity otherwise recognized under Illinois law as eligible for a specific form of exemption similar to those found in the Illinois Business Corporation Act (805 ILCS 5/13.75). A vendor claiming exemption under a specific law must provide a detailed explanation of the legal basis for the claim with its bid or offer and must provide additional detail upon request. If Vendor fails to provide the mandatory documentation with the bid or offer, or does not provide additional detail upon request within the timeframe specified in said request, then the State may deem the Vendor as being non-responsive or not responsible and may disqualify the Vendor.2.33Vendor certifies that, for the duration of this contract it will:post its employment vacancies in Illinois and border states on the Department of Employment Security’s website or its successor system; orwill provide an online link to these employment vacancies so that this link is accessible through the website it successor system; oris exempt from 20 ILCS 1005/1005-47 because the contract is for construction-related services as that term is defined in section 1-15.20 of the Procurement Code; or the contract is for construction and vendor is a party to a contract with a bona fide labor organization and performs construction. (20 ILCS 1005/1005-47). Section 50-37 of the Illinois Procurement Code prohibits political contributions of certain vendors, bidders and offerors. Additionally, section 9-35 of the Illinois Election Code governs provisions relating to reporting and making contributions to state officeholders, declared candidates for State offices and covered political organizations that promote the candidacy of an officeholder or declared candidate for office. The State may declare any resultant contract void if these Acts are violated.Generally, if a vendor, bidder, or offeror is an entity doing business for profit (i.e. sole proprietorship, partnership, corporation, limited liability company or partnership, or otherwise) and has contracts with State agencies that annually total more than $50,000 or whose aggregate pending bids or proposals and current State contracts that total more than $50,000, the vendor, bidder, or offeror is prohibited from making political contributions and must register with the State Board of Elections. 30 ILCS 500/20-160.EVIDENCE OF REGISTRATION WITH THE STATE BOARD OF ELECTIONSIS THE CERTIFICATE OF REGISTRATIONIn accordance with 30 ILCS 500/50-36, each bid, offer, or proposal submitted for a State contract, other than a small purchase defined in Section 20-20 of the Illinois Procurement Code, shall include a disclosure of whether or not the bidder, offeror, or proposing entity, or any of its corporate parents or subsidiaries, within the 24 months before submission of the bid, offer, or proposal had business operations that involved contracts with or provision of supplies or services to the Government of Iran, companies in which the Government of Iran has any direct or indirect equity share, consortiums or projects commissioned by the Government of Iran and: more than 10% of the company’s revenues produced in or assets located in Iran involve oil-related activities or mineral-extraction activities; less than 75% of the company’s revenues produced in or assets located in Iran involve contracts with or provision of oil-related or mineral – extraction products or services to the Government of Iran or a project or consortium created exclusively by that Government; and the company has failed to take substantial action; or the company has, on or after August 5, 1996, made an investment of $20 million or more, or any combination of investments of at least $10 million each that in the aggregate equals or exceeds $20 million in any 12- month period that directly or significantly contributes to the enhancement of Iran’s ability to develop petroleum resources of Iran.A bid, offer, or proposal that does not include this disclosure shall not be considered responsive. We may consider this disclosure when evaluating the bid, offer, or proposal or awarding the contract. FORMCHECKBOX There are no business operations that must be disclosed to comply with the above cited law. FORMCHECKBOX The following business operations are disclosed to comply with the above cited law: Disclosures and Conflicts of InterestThe disclosures hereinafter made by the bidder and its’ subcontractors, as applicable, are each a material representation of fact upon which reliance is placed should the Department enter into the contract with the bidder. The bidder further certifies that the Department has received the disclosure forms for each bid. The chief procurement officer may void the bid, contract, or subcontract, respectively, if it is later determined that the bidder or subcontractor rendered a false or erroneous disclosure. A contractor or subcontractor may be suspended or debarred for violations of the Procurement Code. Furthermore, the chief procurement officer may void the contract and the surety providing the performance bond shall be responsible for completion of the contract.Financial Interests and Conflicts of InterestSection 50-35 of the Illinois Procurement Code provides that all bids of more than $25,000 shall be accompanied by disclosure of the financial interests of the bidder. This disclosed information for the successful bidder, will be maintained as public information subject to release by request pursuant to the Freedom of Information Act, filed with the Procurement Policy Board, and shall be incorporated as a material term of the contract. Furthermore, pursuant to Section 5-5, the Procurement Policy Board may review a proposal, bid, or contract and issue a recommendation to void a contract or reject a proposal or bid based on any violation of the Procurement Code or the existence of a conflict of interest as provided in subsections (b) and (d) of Section 50-35.The financial interests to be disclosed shall include ownership or distributive income share that is in excess of 5%, or an amount greater than 60% of the annual salary of the Governor, of the bidding entity or its parent entity, whichever is less, unless the contractor or bidder is a publicly traded entity subject to Federal 10K reporting, in which case it may submit its 10K disclosure in place of the prescribed disclosure. If a bidder is a privately held entity that is exempt from Federal 10K reporting, but has more than 400 shareholders, it may submit the information that Federal 10K companies are required to report, and list the names of any person or entity holding any ownership share that is in excess of 5%. The disclosure shall include the names, addresses, and dollar or proportionate share of ownership of each person making the disclosure, their instrument of ownership or beneficial relationship, and notice of any potential conflict of interest resulting from the current ownership or beneficial interest of each person making the disclosure having any of the relationships identified in Section 50-35 and on the disclosure form. The current annual salary of the Governor is $177,412.00.In addition, all disclosures shall indicate any other current or pending contracts, proposals, leases, or other ongoing procurement relationships the bidding entity has with any other unit of state government and shall clearly identify the unit and the contract, proposal, lease, or other relationship.Disclosure Forms. Disclosure Form is attached for use concerning the individuals meeting the above ownership or distributive share requirements. Subject individuals should be covered each by a separate form. The forms must be included with each bid. STATE OF ILLINOISFINANCIAL DISCLOSURES AND CONFLICTS OF INTEREST January 2013Financial Disclosures and Conflicts of Interest forms (“forms”) must be accurately completed and submitted by the vendor, any parent entity(ies) and any subcontractors. There are nine steps to this form and each must be completed as instructed in the step heading, unless otherwise provided. A bid, offer, or proposal that does not include this form shall be considered non-responsive. The Agency/University will consider this form when evaluating the bid, offer, or proposal or awarding the contract.The requirement of disclosure of financial interests and conflicts of interest is a continuing obligation. If circumstances change and the previously submitted form is no longer accurate, disclosing entities must provide an updated form.Separate forms are required for the vendor, any parent entity(ies) and any subcontractors.Subcontractor forms must be provided with a copy of the subcontract, if required, within 15 days after execution of the State contract or after execution of the subcontract, whichever is later, for all subcontracts with an annual value of more than $50,000.This disclosure is submitted for:? Vendor?Vendor’s Parent Entity(ies) (100% ownership)?Subcontractor(s) >$50,000 Annually?Subcontractor’s Parent Entity(ies) > $50,000 AnnuallyProject Name Illinois Procurement Bulletin Number / CDB Project No.Contract NumberVendor NumberDoing Business As (DBA)Disclosing EntityDisclosing Entity’s Parent EntitySubcontractorInstrument of Ownership or Beneficial InterestPlease Circle One:Sole ProprietorshipCorporate Stock (C – Corporation, Professional Corporation, Service Corporation)Limited Liability Company Membership Agreement (Series LLC, Low-Profit Limited Liability Company)Partnership Agreement (General Partnership, Limited Partnership, Limited Liability Limited Partnership)Not-for-Profit CorporationTrust Agreement (Beneficiary Other - If you selected Other, please describe: EP 1STEP 1SUPPORTING DOCUMENTATION SUBMITTAL(All vendors complete regardless of annual bid, offer, or contract value)(Subcontractors with subcontract annual value of more than $50,000 must complete)You must select one of the six options below and select the documentation you are submitting. You must provide the documentation the applicable section requires with this form.? Option 1 – Publicly Traded Entities1.A.?Complete Step 2, Option A for each qualifying individual or entity holding any ownership or distributive income share in excess of 5% or an amount greater than 60% ($106,447.20) of the annual salary of the Governor.OR1.B.? Attach a copy of the Federal 10-K, and skip to Step 3.? Option 2 – Privately Held Entities with more than 200 Shareholders2.A.?Complete Step 2, Option A for each qualifying individual or entity holding any ownership or distributive income share in excess of 5% or an amount greater than 60% ($106,447.20) of the annual salary of the Governor.OR2.B. ?Complete Step 2, Option A for each qualifying individual or entity holding any ownership share in excess of 5% and attach the information Federal 10-K reporting companies are required to report under 17 CFR 229.401.? Option 3 – All other Privately Held Entities, not including Sole Proprietorships3.A. ?Complete Step 2, Option A for each qualifying individual or entity holding any ownership or distributive income share in excess of 5% or an amount greater than 60% ($106,447.20) of the annual salary of the Governor.?Option 4 – Foreign Entities4.A. ?Complete Step 2, Option A for each qualifying individual or entity holding any ownership or distributive income share in excess of 5% or an amount greater than 60% ($106,447.20) of the annual salary of the Governor.OR4.B. ? Attach a copy of the Securities Exchange Commission Form 20-F or 40-F and skip to Step 3.? Option 5 – Not-for-Profit Entities?Complete Step 2, Option B.? Option 6 – Sole Proprietorships?Skip to Step 3.STEP 2DISCLOSURE OF FINANCIAL INTEREST OR BOARD OF DIRECTORS(All vendors, except sole proprietorships, must complete regardless of annual bid, offer, or contract value)(Subcontractors with subcontract annual value of more than $50,000 must complete)Complete either Option A (for all entities other than not-for-profits) or Option B (for not-for-profits). Additional rows may be inserted into the tables or an attachment may be provided if needed.OPTION A – Ownership Share and Distributive IncomeOwnership Share – If you selected Option 1.A., 2.A., 2.B., 3.A., or 4.A. in Step 1, provide the name and address of each individual and their percentage of ownership if said percentage exceeds 5%, or the dollar value of their ownership if said dollar value exceeds $106,447.20.? Check here if including an attachment with requested information in a format substantially similar to the format below.TABLE – XNameAddressPercentage of Ownership$ Value of OwnershipDistributive Income – If you selected Option 1.A., 2.A., 3.A., or 4.A. in Step 1, provide the name and address of each individual and their percentage of the disclosing vendor’s total distributive income if said percentage exceeds 5% of the total distributive income of the disclosing entity, or the dollar value of their distributive income if said dollar value exceeds $106,447.20. ? Check here if including an attachment with requested information in a format substantially similar to the format below.TABLE – Y NameAddress% of Distributive Income$ Value of Distributive IncomePlease certify that the following statements are true.I have disclosed all individuals or entities that hold an ownership interest of greater than 5% or greater than $106,447.20.? Yes ? NoI have disclosed all individuals or entities that were entitled to receive distributive income in an amount greater than $106,447.20 or greater than 5% of the total distributive income of the disclosing entity.? Yes ? NoOPTION B – Disclosure of Board of Directors (Not-for-Profits)If you selected Option 5 in Step 1, list members of your board of directors. Please include an attachment if necessary.TABLE – Z Name AddressSTEP 3DISCLOSURE OF LOBBYIST OR AGENT(Complete only if bid, offer, or contract has an annual value over $25,000)(Subcontractors with subcontract annual value of more than $50,000 must complete)? Yes ? No. Is your company represented by or do you employ a lobbyist or other agent required to register under the Lobbyist Registration Act (lobbyist must be registered pursuant to the Act with the Secretary of State) or other agent who is not identified through Step 2, Option A above and who has communicated, is communicating, or may communicate with any State/Public University officer or employee concerning the bid or offer? If yes, please identify each lobbyist and agent, including the name and address below.If you have a lobbyist that does not meet the criteria, then you do not have to disclose the lobbyist's information.Name AddressRelationship to Disclosing EntityDescribe all costs/fees/compensation/reimbursements related to the assistance provided by each representative lobbyist or other agent to obtain an Agency/University contract: STEP 4PROHIBITED CONFLICTS OF INTEREST(All vendors must complete regardless of annual bid, offer, or contract value)(Subcontractors with subcontract annual value of more than $50,000 must complete)Step 4 must be completed for each person disclosed in Step 2, Option A and for sole proprietors identified in Step 1, Option 6 above. Please provide the name of the person for which responses are provided: Do you hold or are you the spouse or minor child who holds an elective office in the State of Illinois or hold a seat in the General Assembly?? Yes ? NoHave you, your spouse, or minor child been appointed to or employed in any offices or agencies of State government and receive compensation for such employment in excess of 60% ($106,447.20) of the salary of the Governor?? Yes ? No Are you or are you the spouse or minor child of an officer or employee of the Capital Development Board or the Illinois Toll Highway Authority?? Yes ? NoHave you, your spouse, or an immediate family member who lives in your residence currently or who lived in your residence within the last 12 months been appointed as a member of a board, commission, authority, or task force authorized or created by State law or by executive order of the Governor?? Yes ? No If you answered yes to any question in 1-4 above, please answer the following: Do you, your spouse, or minor child receive from the vendor more than 7.5% of the vendor’s total distributable income or an amount of distributable income in excess of the salary of the Governor ($177,412.00)?? Yes ? NoIf you answered yes to any question in 1-4 above, please answer the following: Is there a combined interest of self with spouse or minor child more than 15% in the aggregate of the vendor’s distributable income or an amount of distributable income in excess of two times the salary of the Governor ($354,824.00)?? Yes ? NoSTEP 5POTENTIAL CONFLICTS OF INTEREST RELATING TO PERSONAL RELATIONSHIPS(Complete only if bid, offer, or contract has an annual value over $25,000)(Subcontractors with subcontract annual value of more than $50,000 must complete)Step 5 must be completed for each person disclosed in Step 2, Option A and for sole proprietors identified in Step 1, Option 6 above.Please provide the name of the person for which responses are provided: Do you currently have, or in the previous 3 years have you had State employment, including contractual employment of services?? Yes ? NoHas your spouse, father, mother, son, or daughter, had State employment, including contractual employment for services, in the previous 2 years?? Yes ? NoDo you hold currently or have you held in the previous 3 years elective office of the State of Illinois, the government of the United States, or any unit of local government authorized by the Constitution of the State of Illinois or the statutes of the State of Illinois?? Yes ? NoDo you have a relationship to anyone (spouse, father, mother, son, or daughter) holding elective office currently or in the previous 2 years?? Yes ? NoDo you hold or have you held in the previous 3 years any appointive government office of the State of Illinois, the United States of America, or any unit of local government authorized by the Constitution of the State of Illinois or the statutes of the State of Illinois, which office entitles the holder to compensation in excess of expenses incurred in the discharge of that office?? Yes ? NoDo you have a relationship to anyone (spouse, father, mother, son, or daughter) holding appointive office currently or in the previous 2 years?? Yes ? NoDo you currently have or in the previous 3 years had employment as or by any registered lobbyist of the State government?? Yes ? NoDo you currently have or in the previous 2 years had a relationship to anyone (spouse, father, mother, son, or daughter) that is or was a registered lobbyist?? Yes ? NoDo you currently have or in the previous 3 years had compensated employment by any registered election or re-election committee registered with the Secretary of State or any county clerk in the State of Illinois, or any political action committee registered with either the Secretary of State or the Federal Board of Elections?? Yes ? NoDo you currently have or in the previous 2 years had a relationship to anyone (spouse, father, mother, son, or daughter) who is or was a compensated employee of any registered election or reelection committee registered with the Secretary of State or any county clerk in the State of Illinois, or any political action committee registered with either the Secretary of State or the Federal Board of Elections?? Yes ? NoSTEP 6EXPLANATION OF AFFIRMATIVE RESPONSES(All vendors must complete regardless of annual bid, offer, or contract value)(Subcontractors with subcontract annual value of more than $50,000 must complete)If you answered “Yes” in Step 4 or Step 5, please provide on an additional page a detailed explanation that includes, but is not limited to the name, salary, State agency or university, and position title of each individual.STEP 7POTENTIAL CONFLICTS OF INTERESTRELATING TO DEBARMENT & LEGAL PROCEEDINGS(Complete only if bid, offer, or contract has an annual value over $25,000)(Subcontractors with subcontract annual value of more than $50,000 must complete)This step must be completed for each person disclosed in Step 2, Option A, Step 3, and for each entity and sole proprietor disclosed in Step 1.Please provide the name of the person or entity for which responses are provided: Within the previous ten years, have you had debarment from contracting with any governmental entity?? Yes ? NoWithin the previous ten years, have you had any professional licensure discipline?? Yes ? NoWithin the previous ten years, have you had any bankruptcies?? Yes ? NoWithin the previous ten years, have you had any adverse civil judgments and administrative findings?? Yes ? NoWithin the previous ten years, have you had any criminal felony convictions?? Yes ? NoIf you answered “Yes”, please provide a detailed explanation that includes, but is not limited to the name, State agency or university, and position title of each individual. 8STEP 8DISCLOSURE OF CURRENT AND PENDING CONTRACTS(Complete only if bid, offer, or contract has an annual value over $25,000)(Subcontractors with subcontract annual value of more than $50,000 must complete)If you selected Option 1, 2, 3, 4, or 6 in Step 1, do you have any contracts, pending contracts, bids, proposals, subcontracts, leases or other ongoing procurement relationships with units of State of Illinois government?? Yes ? No. If “Yes”, please specify below. Attach an additional page in the same format as provided below, if desired.Agency/UniversityProject TitleStatusValueContract Reference/P.O./Illinois Procurement Bulletin #Please explain the procurement relationship: STEP 9SIGN THE DISCLOSURE(All vendors must complete regardless of annual bid, offer, or contract value) (Subcontractors with subcontract annual value of more than $50,000 must complete)This disclosure is signed, and made under penalty of perjury for all for-profit entities, by an authorized officer or employee on behalf of the bidder or offeror pursuant to Sections 50-13 and 50-35 of the Illinois Procurement Code. This disclosure information is submitted on behalf of:Name of Disclosing Entity: Signature: Date: Printed Name: Title: Phone Number: Email Address: 6.Taxpayer Identification NumberI certify that:The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), andI am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, andI am a U.S. person (including a U.S. resident alien).If you are an individual, enter your name and SSN as it appears on your Social Security Card. If you are a sole proprietor, enter the owner’s name on the name line followed by the name of the business and the owner’s SSN or EIN. If you are a single-member LLC that is disregarded as an entity separate from its owner, enter the owner’s name on the name line and the D/B/A on the business name line and enter the owner’s SSN or EIN.If the LLC is a corporation or partnership, enter the entity’s business name and EIN and for corporations, attach IRS acceptance letter (CP261 or CP277). For all other entities, enter the name of the entity as used to apply for the entity’s EIN and the EIN.Name: Business Name: Taxpayer Identification Number: Social Security Number: orEmployer Identification Number: Legal Status (check one): FORMCHECKBOX Individual FORMCHECKBOX Governmental FORMCHECKBOX Sole Proprietor FORMCHECKBOX Nonresident alien FORMCHECKBOX Partnership FORMCHECKBOX Estate or trust FORMCHECKBOX Legal Services Corporation FORMCHECKBOX Pharmacy (Non-Corp.) FORMCHECKBOX Tax-exempt FORMCHECKBOX Pharmacy/Funeral Home/Cemetery (Corp.) FORMCHECKBOX Corporation providing or billing FORMCHECKBOX Limited Liability Companymedical and/or health care services (select applicable tax classification) FORMCHECKBOX Corporation NOT providing or billing FORMCHECKBOX D = disregarded entity medical and/or health care services FORMCHECKBOX C = corporation FORMCHECKBOX P = partnershipSignature of Authorized Representative: Date: FORMS B*This Forms B section may be used when responding to an Invitation for Bid (IFB) or a Request for Proposal (RFP) using a current registration in the Illinois Procurement Gateway (IPG).Forms BCertifications and DisclosuresThis FORMS B Section may be used when responding to an Invitation for Bid (IFB) or a Request for Proposal (RFP) and has a current registration in the Illinois Procurement Gateway (IPG). If a vendor does not have a valid IPG registration number, then the vendor must complete and submit the FORMS A Section with their response. Failure to do so may render the submission non-responsive and result in disqualification.Please read this entire section and provide the requested information as applicable. All parts in the FORMS B Section must be completed in full and submitted along with the vendor’s response.Certification of Illinois Procurement Gateway RegistrationMy business has registered with the Illinois Procurement Gateway (IPG). The State of Illinois Chief Procurement Office approved the registration and provided the IPG registration number disclosed in this FORMS B Section. IPG Registration #: IPG Expiration Date: Certification Timely to this SolicitationVendor certifies it is not barred from having a contract with the State based upon violating the prohibitions related to either submitting/writing specifications or providing assistance to an employee of the State of Illinois by reviewing, drafting, directing, or preparing any invitation for bids, a request for proposal, or request of information, or similar assistance (except as part of a public request for such information).? 30 ILCS 500/50-10.5(e), amended by Pub. Act No. 97-0895 (August 3, 2012). FORMCHECKBOX Yes FORMCHECKBOX NoReplacement Certification to IPG Certification #6 (supersedes response in IPG)If Vendor has been convicted of a felony, Vendor certifies at least five years have passed since the date of completion of the sentence for such felony, unless no person held responsible by a prosecutor’s office for the facts upon which the conviction was based continues to have any involvement with the business. ?Vendor further certifies that it is not barred from being awarded a contract.? 30 ILCS 500/50-10. FORMCHECKBOX Yes FORMCHECKBOX NoDisclosure of Lobbyist or Agent (Complete only if bid, offer, or contract has an annual value over $25,000)Is your company or parent entity(ies) represented by or do you or your parent entity(ies) employ a lobbyist required to register under the Lobbyist Registration Act (lobbyist must be registered pursuant to the Act with the Secretary of State) or an agent who has communicated, is communicating, or may communicate with any State/Public University officer or employee concerning the bid or offer? If yes, please identify each lobbyist and agent, including the name and address below. ? Yes ?NoIf yes, please identify each lobbyist and agent, including the name and address below. If you have a lobbyist that does not meet the criteria, then you do not have to disclose the lobbyist’s information.Name AddressRelationship to Disclosing EntityDescribe all costs/fees/compensation/reimbursements related to the assistance provided by each representative lobbyist or other agent to obtain this Agency/University contract:Disclosure of Current and Pending ContractsComplete only if: (a) your business is for-profit and (b) the bid, offer, or contract has an annual value over $25,000. Do not complete if you are a not-for-profit entity. FORMCHECKBOX Yes FORMCHECKBOX No. Do you have any contracts, pending contracts, bids, proposals, subcontracts, leases or other ongoing procurement relationships with units of State of Illinois government?If “Yes”, please specify below. Attach an additional page in the same format as provided below, if desired.Agency/UniversityProject TitleStatusValueContract Reference/P.O./Illinois Procurement Bulletin #SignatureAs of the date signed below, I certify that:My business’ information and the certifications made in the Illinois Procurement Gateway are truthful and accurate.The certifications and disclosures made in this FORMS B Section are truthful and accurate.This FORMS B Section is signed by an authorized officer or employee on behalf of the bidder, offeror, or vendor pursuant to Sections 50-13 and 50-35 of the Illinois Procurement Code, and the affirmation of the accuracy of the financial disclosures is made under penalty of perjury.This disclosure information is submitted on behalf of:Vendor Name: Phone: Street Address: Email: City, State, Zip: Vendor Contact: Signature: Date: Printed Name: Title: ................
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